Advanced Multifocal IOL Technology for the Treatment of Presbyopia, Astigmatism, and Cataract

Supplement to January 2012

and

Advanced multifocal IOL technology for the treatment of presbyopia, astigmatism, and cataract. LENTIS Mplus and LENTIS Mplus Toric LENTIS Mplus and LENTIS Mplus Toric

Advanced multifocal IOL technology for the treatment of presbyopia, astigmatism, and cataract.

MODERATORS Claudio Carbonara, MD, practices at the Detlev R.H. Breyer, MD, is Head of Breyer Eye Carbonara Eye Center and performs surgery Surgery, a private practice and day clinic in at the Primavista Eye Surgery Center, both in Düsseldorf, Germany, and is a Senior Rome. Dr. Carbonara states that he has no Consultant to Marien Hospital in Düsseldorf, financial interest in the products or compa- Germany. Dr. Breyer states that he has no financial inter- nies mentioned. He may be reached at e-mail: carbo- est in the products or companies mentioned. He may be [email protected]. reached at tel: +49 211 5867 5726; e-mail: d.breyer@breyer-augenchirurgie.de. Anders Granberg, MD, is a Medical Director. Dr. Granberg did not provide financial disclo- Erik L. Mertens, MD, FEBOphth, is Medical sure information. He may be reached at e- Director of Medipolis, Antwerp, Belgium. Dr. mail: [email protected]. Mertens states that he is a consultant to Topcon. He may be reached at tel: +32 3 828 Johnny Moore, MD, PhD, is the Medical 29 49; e-mail: [email protected]. Director, Cathedral Eye Clinic and a Consultant in anterior segment, cataract, and PARTICIPANTS refractive surgery at Royal Victoria Hospital Jaime Aramberri, MD, practices at the Begitek Belfast, both in the United Kingdom. Dr. Ophthalmology Clinic, San Sebastian, Spain, Moore states that he is a consultant to Topcon. He may and the Okular Ophthalmology Clinic, be reached at e-mail: [email protected]. Vitoria, Spain. Dr. Aramberri states that he has no financial interest in the products or companies Dominique Pietrini, MD, practices at the mentioned. He may be reached at e-mail: jaimearamber- Clinique de la Vision, Paris. Dr. Pietrini states [email protected]. that he has no financial interest in the products or companies mentioned. He may be Gerd U. Auffarth, MD, FEBOphth, is Chairman reached at tel: +33 1 58 05 2000; fax: +33 1 58 of the Department of Ophthalmology, 05 2001; e-mail: [email protected]. University of Heidelberg, Germany. Professor Auffarth states that he has performed contract Jan A. Venter, MD, is the Medical Director for Optical research for Oculentis. He may be reached at e- Express. Dr. Venter states that he has no financial interest mail: [email protected]. in the products or companies mentioned. He may be reached at e-mail: [email protected]. Edmondo Borasio, MedCBQ Ophth, FEBO, is a Consultant in cataract, corneal, and refractive surgery at Moorfields Eye Hospital, Dubai, UAE. Dr. Borasio states that he is a paid consultant to Oculentis and a shareholder of EB EYE Ltd, producer of Eye Pro and the BESSt IOL Power Calculator. He may be reached at tel: +971 4 4297888; fax: +971 4 363 5339; e-mail: [email protected].

2 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012 Advanced Multifocal IOL Technology

Oculentis GmbH recently invited a panel of world-renowned right now, my rate for surgeons to convene for a discussion on the LENTIS Mplus and retreatment after IOL LENTIS Mplus Toric IOLs. These lenses are both presbyopia-cor- implantation with the recting, multifocal IOLs with a refractive design; however, they Mplus is below 5%. As represent a completely new approach in multifocal lens tech- we are on target in more nology due to each of the lenses’ innovative sector-shaped near than 95% of our cases, I vision section (Figure 1), providing HD-vision-natural contrast feel that this eludes to sensitivity, no image jumps, and excellent distance and near the fact that we are BCVA. doing it correctly. What we must remem- TALKING POINT NO. 1: ber is that this kind of PRESBYOPIC LENS EXCHANGE patient is aiming for real Breyer: The reason that we are gathered together is emmetropia. Anything because we all agree that Oculentis’ LENTIS Mplus and Mplus above a difference of Toric IOLs are wonderful new products. We all have implant- 0.50 D from the target Figure 1. The Mplus Toric IOL.The ed these lenses in our patients—some of us have implanted refraction, and the lens’sector-shaped near vision seg- hundreds while others of us are in the beginning stages and patient will need a laser ment enhances contrast sensitivity. are still learning what this lens can do. The fact that we have enhancement. such a diverse range of experience among us today will make this roundtable very lively. I am sure we will all walk away Granberg: I am a medical director in Sweden. We have 24 from this discussion having learned something new. clinics across the country, and we mainly do laser vision cor- I would like to begin by talking about the treatment of rection and refractive lens exchange procedures. We do presbyopia and astigmatism. Specifically, how many of you presbyopic lens exchange on most of our patients. We have are doing routine presbyopic lens exchange, and if you are, done some emmetropes, but we have a very careful patient how many of those IOLs are you exchanging for the Mplus? selection process in this population. We started implanting the Mplus in October 2010. To Aramberri: My practice is mainly a refractive surgery date, we have implanted this lens in more than 2,000 eyes. practice, and I have been implanting the Mplus as a lens- We then started with the Mplus Toric in February 2011 and based refractive option since 2009. Although I do perform have already implanted this lens in approximately 350 eyes. refractive lens surgery, I will not perform presbyopic lens The main feeling across our centers is that the Mplus and exchange except in the definition of emmetropic surgery. I the Mplus Toric are really good lenses. We have no buts any- normally will not perform refractive lens surgery in more; there simply are not the side effects we have seen emmetropes, as I prefer to treat patients with previous with other multifocal IOLs. We used to mix-and-match the refractions. This consists mainly of hyperopes, but I also AcrySof ReStor (Alcon Laboratories, Inc.) with another IOL, treat some myopes as well as patients who are between the and the results were favorable. But now that we are using ages of 50 and 55 years old. I might do some emmetropes the Mplus, we are even more confident in our results. mainly after 60 years old, and right now I have to say that the lens I use most is the Mplus. Breyer: It sounds as if you have completely shifted from the ReStor to the Mplus. Do you see any indications for the Breyer: I have had the experience that hyperopic patients ReStor? turn out to be a little bit on the hyperopic side after surgery. Therefore, I target slight myopia. Let me explain: If you Granberg: No. I was not satisfied with the outcomes implant a Mplus Toric in a hyperopic patient, their refrac- using the ReStor, as you had to mix-and-match. However, it tion will end up closer to 0.25 D. To compensate, I aim for a was the best available option until the Mplus entered the refractive target of -0.25 to -0.50 D instead of plano. Has market. anyone else seen this? Breyer: When a patient wants very good near vision after Aramberri: It depends on how you perform your calcu- lens implantation, I previously chose the AT.LISA (Carl Zeiss lations. I do ray tracing, using my own model first and then Meditec) or the Tecnis Multifocal (Abbott Medical Optics checking the results against the regular formulas. I do not Inc.). This may begin to change now that the Mplus is in my have the radius or thickness data for this lens, so I calculat- rotation. Do you think that these and other multifocal IOLs ed the IOL power using data from another modern lens can compete with the Mplus? and added the difference in the A-constant of these lenses. This seems to have worked, as our refractive results with Granberg: No, and that is why we have changed com- the Mplus have been excellent thus far. I can tell you that, pletely to the Mplus. This lens is pupil independent, and

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therefore patients have fewer problems with night vision. Of confidence in the Mplus that the surgeon sees the patient course there are still a small number of patients who com- on the day of surgery for the first time. plain of these problems, but, in the majority of cases, We started implanting this lens in December 2009. Of the patients are satisfied. 10,000 eyes we have implanted, we have results for 8,000. Of these, 90% are implanted in myopic or hyperopic patients Carbonara: I practice in a private eye surgery center in with clear lenses, but we will not do clear lens exchange in Rome. I prefer not to perform refractive lens exchange; how- plano or emmetropic patients. ever, in some cases when the refractive error is very high, I According to our results, 80% of patients achieved 20/20 will do it. In my everyday practice, I have changed complete- or better UCVA, and 91% achieved 20/40 or better near ly from implanting the AcrySof ReStor to the Mplus, or to UCVA. Additionally, 70% were within ±0.50 D of the Mplus Toric when appropriate. I have been impressed emmetropia, and only 6% of patients complained of signifi- with both designs, and my patients have had a high satisfac- cant night-driving problems. tion rate with both models. They provide good distance and near vision, even after 1 day after surgery. Therefore, I Pietrini: I work in a private refractive center in Paris, and I have stopped implanting any other type of multifocal IOL. do mainly refractive surgery. My approach is perhaps a bit different from the other panelists, because I tend to per- Borasio: I practice at Moorfields Eye Hospital in Dubai. I form laser surgery to correct presbyopia. As I see it, presby- have to say that, generally speaking, I have never been a opic lens exchange is mainly for patients older than 55 or 60 strong supporter of multifocal technology because of the years of age, when laser surgery is no longer indicated. issues with contrast sensitivity and reduced image quality. I have tried other diffractive multifocal lenses for the cor- Only when I heard good reports about the Mplus from col- rection of astigmatism in the past with very good results. leagues of mine did I become curious; I really wanted to see But, what is lost for the patient is intermediate vision. When how this concept of bifocal multifocality would work. So far I moved to implanting the Mplus, I found a real improve- with the Mplus, I have had happy patients. They often ment in terms of intermediate vision for the patient. There come back with big smiles—more than what I am seeing were no more complaints of night vision problems, which after monofocal IOL implantation. Therefore, I am moving my patients frequently complained of with the other multi- forward to implant these lenses more often, and I am focal IOLs. Therefore, I have shifted treatment of presbyopia expanding my range of corrections. in all my refractive cases to the Mplus Toric for the correc- We do offer presbyopic refractive lens exchange regard- tion of astigmatism. less of the patient’s refractive error. We would implant the Mplus in emmetropic patients who wish for spectacle inde- Moore: I work in both a University hospital practice and a pendence as long as they have some degree of lenticular private practice setting in Belfast, United Kingdom. I have opacity. I do not do clear lens extraction in emmetropic implanted Mplus IOLs in approximately 700 patients. The eyes with a clear crystalline lens. majority of these patients have been myopic, hyperopic, and astigmatic presbyopes. Unlike Dr. Venter, I do use the Mplus Breyer: Will you do it on higher myopes? In my experi- in emmetropic presbyopes; however, in these cases, I tend to ence, patients from Dubai often have extremely long eyes. treat only the nondominant eye. I have found this approach to be useful, although adaptation to glare does take longer Borasio: I have done some very high myopes with good than it does in patients who have two eyes treated. We rou- results. The main problem with treating patients with high tinely assess each patient with our validated subjective quali- myopia is their high expectations. ty of vision questionnaire. This way we are able to carefully follow both the initial induced level of dysphotopsia and the Venter: There are 40 Optical Express clinics in the United overall quality of vision, as well as the patient’s ability to Kingdom, and each clinic performs laser vision correction as nearoadapt to the IOL. We are finding it is a useful method well as refractive lens exchange/cataract procedures. We to assess and compare between patients and between IOLs. have used many different multifocal IOLs including the I do not do presbyopic laser treatments other than Tecnis, AcrySof IQ ReStor, and the AT.LISA, and to date we micro-monovision laser vision correction in those patients have done more than 10,000 Mplus implants and in excess averse to any form of intraocular treatment. I am consider- of 500 Mplus Toric implants. During the patient counseling ing commencing the use of the Schwind laser presbyopic process, which is performed by an optometrist, we currently approach, which is relatively gentle on the cornea by com- counsel all patients on the Mplus lens. Ninety-five percent bining micro-monovision and modifications of higher-order of all patients who are treated at one of our centers will aberrations. receive the Mplus. It is only in patients who have a con- traindication, such as macular degeneration or severe Auffarth: I have to say that, of all the multifocal toric amblyopia, that we won’t use the Mplus. We have so much IOLs on the market, the best experience we have had has

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about the Mplus was in early 2009, just as the European tri- A als began. At that time, I really could not tell if this lens was going to work, but I feared that it would induce coma and affect visual quality. Some of my colleagues were trying the lens, and it worked for them. Since my first implantation, I realized that the Mplus did not affect contrast sensitivity, and it also improved patients’ visual quality. I have implanted thousands of lenses and experimented with many designs, but I quickly realized from the first patient that this perception of vision loss was not there. Patients were seeing 20/20 on the first day after B surgery. The only matter remaining in some cases was not enough near focal plane. I have shifted completely to this lens design.

Breyer: Have you seen any drawbacks?

Aramberri: The Mplus is pupil independent—this is an advantage—but because the near-vision sector is asymmetric, it demands perfect pupil centration. If this lens becomes decentered, visual symptoms will result, but centration with a diffractive optic is less sensitive. If the diffrac- Figure 2. (A) The optic of the LENTIS Mplus is 6 mm; the total tive optic becomes decentered, the visual impact is not as diameter of the IOL is 11 mm.(B) The LENTIS Mplus is stable in apparent. the capsular bag. Moore: Early symptoms of dysphotopsia in some been with the Mplus Toric. The loss of light is the lowest patients prompted me to assess the use of the IOL with the among all of the multifocal lenses, and the accuracy of the near segment implanted in a superior position. Overall, this IOL manufacturing is excellent. Another good thing about seemed to slightly reduce early dysphotopsic symptoms, the Mplus Toric is that the lens is always implanted in the but it had no long-term advantage. It did produce a small same position; there is no need to rotate the lens toward number of cases in which near vision was poor. Several of the axis of astigmatism. You just implant it at the 12- these patients responded well when the IOL was rotated to o’clock position (90º), and it always fits well in the eye. I position the near segment inferiorly. have yet to see a case in which the lens decenters, and this is much more than I can say for competing lenses from Breyer: Jamie, have you changed anything in your preop- other companies. erative examination to look at the pupil shift? We perform many kinds of presbyopia treatments, and although we tend to use Intracor or Supracor for patients Aramberri: I have, but not because of what I just said. I with emmetropia, I have no problem implanting the Mplus cannot predict the relative centration of the capsular bag in emmetropes. with respect to the pupil in advance; I can only tell that once the lens is implanted. In patients with small pupils, TALKING POINT NO. 2: NEAR-VISION SEGMENT however, the pupil occludes the inferior segment, limiting Breyer: This is an impressive roundtable thus far. Many of exposure of the area that provides near vision. Therefore, us here are high-volume surgeons who have transitioned to we will not implant the Mplus in patients with a pupil the LENTIS Mplus from other IOL technologies. We all smaller than 3.5 mm. Pupillometry, in return, has become understand that the LENTIS Mplus incorporates a new opti- more relevant with this lens than with previous lenses. cal concept (Figure 2A). Its optical rotation is asymmetrical, with the shape of the near-vision segment providing seam- Venter: Most of our patients are between 40 and 60 less transitions between near and far vision zones. In your years old and are refractive lens exchange patients who experiences, is this design only an advantage or is there also happen to have very high expectations. Therefore, we do a disadvantage? Is your surgical planning with this new look at pupil size, and we give every patient a questionnaire design based on pupil size and decentration? that they must answer at 1, 3, and 12 months following surgery. What we have found is that pupils larger than 7 mm Aramberri: Surgeons mainly talk about empiric results— have an increased incidence in glare. Therefore, we do not but a lens either works or it does not. The first time I heard use the 3.00 D add in a pupil that is more than 7 mm; we

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will use the 1.50 D add lens. I think that is really helpful in if there are small problems after surgery we have the docu- managing those patients. mentation of pupillary parameters and are able to learn from these data to better understand and meet patients’ Granberg: I am not as concerned with pupil size. We needs in the future. started implanting the lens shortly after learning about it at the European Society of Cataract and Refractive Surgeons Auffarth: Those patients who typically receive an Mplus (ESCRS) meeting in Paris in 2010, and we have seen really no IOL are looking for presbyopia treatment, and therefore drawbacks. I was skeptical at first when I saw the design, but they are usually grouped as refractive patients. We always it works. However, we have some patients with unexpected perform pupillometry before any type of refractive surgery; glare or halos that we can’t explain. for a cataract patient, however, I would not do pupillometry. The average pupil size for a 70- to 80-year-old patient is Aramberri: This is usually a result of decentration. 3.5 mm, which is more than sufficient for this lens. Below that age, the pupil is even larger. Granberg: That is what I suspect, as we have not been I would also like to address the problem with centration, overly concerned with pupil size. Our cutoff for implanta- which is the same for every kind of multifocal lens. If you tion is a pupil size of 2.5 mm or smaller. have a 1- to 2-mm decentration, even the Tecnis or the ReStor will give you some problems, especially if you are Aramberri: I have to say that this phenomenon was more implanting the toric version. For this reason, I would not frequent with the previous platform (312) than it is with the over-emphasize the use of pupillometry. If you have a glau- new platform (313). The 313 has improved stability and coma patient with a 1.5-mm pupil, there will always be a centration through postoperative long-term results. In my problem, but those patients are contraindicated. experience, after 1 year of only implanting the 313, I have A refractive patient needs a complete exam, and this seen not one case of symptomatic IOL decentration. includes pupillometry, but I would not say that the lens demands this. Moore: I agree that the new platform enhances results, both in long-term stability and even early visual recovery. TALKING POINT NO. 3: Whether the early visual recovery is also related to an overall IMPLANTATION, LENS POSITION improved IOL stability, I am unsure. Borasio: The optical properties of this asymmetric multifocal lens are still to be completely understood. It would Carbonara: I routinely implant a capsular tension ring be interesting to find out whether this near vision sector (CTR), so I have not seen any tilting with the Mplus. But has to be that big. If it could be smaller, for example, we my numbers are not as big as the numbers the other sur- might be able to reduce the incidence of glare even more. geons in this room have had. Decentration is not the I also wonder if this segment must be located inferiorly. largest issue here. What is really important is that there Has anyone tried to shift it? I was thinking that fewer are no cases of posterior capsular opacification (PCO) halos and less glare might result if this segment was posi- after implantation of the Mplus, which in comparison is tioned on the temporal side. When the light comes from very frequent with the AcrySof ReStor. This is one of the the temporal side, it does not hit the temporal side, and reasons why I am satisfied with this Mplus lens. I have when it comes from the nasal side, it hits it less because of even operated on two young ladies with cataract and the nose in between. It would be interesting to have com- high myopia who normally wore contact lenses. I was parative studies with different positions of the additional doubtful that they would be satisfied with their near sector. vision after surgery; we all know how good the near vision is in high myopes. These two patients were happy, and Venter: We have implanted the plate-haptic lens design they reported good vision with the laptop and did quite upside down, and we have seen significant improvements in well with desktop computers. Although their vision the lens’ performance. We have also implanted it horizontal- becomes a bit blurry when they are 1 m away from the ly with good results. Both placements have minimized the monitor, for all the other daily activities they are absolute- incidence of halos and glare. ly happy. Additionally, I prefer not to implant this lens if the pupil is too small, which for me is anything smaller Borasio: Do you always implant the lens upside down? than 2.5 mm. Venter: No, but if the patient has excessive glare I will go Breyer: I also feel that there is a need for pupillometry back in and rotate the lens into an upside down position. and documentation of pupil shift in relation to the visual axis before surgery. An excellent and easy-to-use tool for this Borasio: Why not just implant it upside down from the purpose is the KR-1W aberrometer from Topcon. Therefore, start, then?

6 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012 Advanced Multifocal IOL Technology Courtesy of Gerd U. Auffarth, MD Courtesy of Gerd U. Auffarth, MD

Figure 3. Luminous efficiancy on optical bench for the M- Figure 4. Lens optical images, rings, or segment. Comparing Flex, ReZoom,Tecnis, and LENTIS Mplus IOLs. Both refractive the screen images of the three multifocal concepts, the Mplus lenses (M-Flex and ReZoom) show diffuse foci compared to segment lens (bottom right) shows less loss of light than the the diffractive (Tecnis) or segment (Mplus) model with two refractive (ReZoom and M-Flex) or diffractive (Tecnis) lenses. defined foci for near and distance vision.

Venter: You can. And the reading will be the same.

Borasio: And temporally? Have you tried that as well?

Venter: Yes, and these patients will have good near (read-

ing) vision as well. However, with the C-loop design we have Courtesy of Gerd U. Auffarth, MD seen some loss of reading vision, and I think that might be because the lens does not center that well. (We do not use CTRs.)

Moore: I have found a small number of patients with poor or no near vision when the near segment is placed superiorly; however, they have responded well to rotation to an inferior position. In each case, the patient had small Figure 5.Modular transfer function.Energy loss experienced pupils (less than or equal to 3 mm) and had a pronounced with the Mplus, M-Flex, AT.LISA, ReStor, and Tecnis IOLs. inferior nasal shift with the near synkinesis. IOL designs. My experience thus far is only with the plate- Aramberri: IOL decentration with the C-loop design may haptic—although it is not really a plate-haptic but a one- be causative of loss of vision. In many cases, once you have piece IOL. I do not like the term plate-haptic, because our centered the lens, it does not matter if it is oblique; the visu- experience with these IOLs dictates that they are likely to al function remains more or less the same. Another applica- rotate in the capsular bag, causing various complications. tion of this asymmetric optic is to compensate for preexist- The design of the Mplus is more of a four-haptic IOL, ing corneal coma. In cases with a mild keratoconic pattern, I because there are four plates on the IOL. That is the reason might implant the lens upside down to compensate for the why this model is extremely stable in the capsular bag coma. In these cases, I am not looking for presbyopic cor- (Figure 2B) and why there are no major complications. In rection but for visual function improvement. fact, the Mplus is so stable that the IOL is difficult to manip- ulate, especially when the OVD is removed from the eye. Breyer: Very interesting point. (Editor’s Note: After this I have one case that, due to surgical manipulation, the IOL roundtable discussion took place, Dr. Breyer said that he com- would not stay in the right axis. There was also a traumatic pletely changed to implanting the Mplus upside down, with injury of the zonula, and there was evidence of IOL tilt. As a good results. He said that patients complain even less of halos result, the patient lost visual acuity. With the exception of and glare.) this outlying case, I have been impressed with the quality of vision and the absence of coma after implantation of the Pietrini: The shape of the addition is quite surprising, but Mplus. There is typically no incidence of tilt with this IOL. the results are there. One of the interesting things about this lens is that there is no optic rupture. Therefore, in terms of Auffarth: Some patient complaints immediately after sur- patient comfort, it is probably better than other multifocal gery are not related to the lens. A lot of complaints that we

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have heard from patients are, in fact, related to surface lubri- Courtesy of Gerd U. Auffarth, MD cation. Very often patients describe dry eye symptoms that can also be related to the lens, because there is loss of near vision. But, if you prescribe a good dry eye treatment, then these kinds of problems go away pretty quickly. This is an important point, because some surgeons who try a new type of lens are unaware of what kind of symptoms patients will have after implantation. If the patient is describing symptoms that sound like dry eye problems, the Figure 6. The above images were all recorded with the same surgeon must take measures to address them. camera integration time (33 ms). Images shown are for far and near at the maximum modular transfer function. Breyer: This is a very good, and underestimated, point. We routinely advise patients who elect multifocal IOL she is absolutely happy with the end result (and asked me implantation to use artificial tears as well as steroids and why I didn’t implant this IOL 2 years ago). antibiotics after surgery. Aramberri: I think that Gerd’s pictures correlate with TALKING POINT NO. 4: CONTRAST SENSITIVITY what we have seen in our patients. The absence of Breyer: With the Mplus, contrast sensitivity is exceptional decreased visual sensation is what has impressed us most after surgery, in contrast to other rotationally symmetrical about the Mplus. We no longer hear of patients complain- multifocal IOLs. Professor Auffarth has some very interesting ing of foggy vision or not seeing well. I would like to say a images that depict the level of contrast sensitivity that is word in defense of diffractive lenses, as I have implanted typical of various multifocal IOL designs. many. Most of my patients who have received a diffractive multifocal IOL are happy, but it was that small number of Auffarth: Figures 3 through 6 can be used to compare patients who complained that really annoyed me, and that contrast sensitivity with the LENTIS Mplus to contrast sensi- is what made me turn away from diffractive IOLs. Those tivity with the M-Flex, the ReZoom (Abbott Medical Optics patients just weren’t as happy as LASIK patients. But with Inc.), and the Tecnis Multifocal. The first thing that you can the Mplus, there is improved contrast sensitivity function, see from this series of figures is that the Mplus is similar to and it has brought me joy again in performing IOL surgery. the other refractive lenses in that it creates two foci. So even though this lens only has a small segment, it still creates a Granberg: We also transitioned to the Mplus because of full image just like the other lenses. Figure 4 shows the rings this improvement in contrast sensitivity. I operated on one of the refractive lens, and you can get a feel for how it differs of our optometrists who lives in North Sweden, and he flew from the diffractive pattern. Our experiment used a stan- into Stockholm for surgery. That evening after surgery, when dardized set-up so that the same amount of light was pro- he was flying home, he was able to read the newspaper in jected onto each lens. In theory, the same amount of light the dim lighting conditions in the cabin. He was so happy should come out from each IOL. What we saw, however, is with his outcome, and he was -5.00 D. that much more light came out from the Mplus than from the other IOLs. We have done some other studies on the Carbonara: A few weeks ago, I was looking at optical bench to measure the lens power, the modular Oculentis’ Web site and downloaded Professsor Auffarth’s transfer function, and the energy loss (Figures 5 and 6). Here paper on the contrast sensitivity of the Mplus (Figure 7).1 we determined energy loss was 22% with the Tecnis I was a bit skeptical, because it seemed to me that this Multifocal and the ReStor Natural, 19% with the AT.LISA, lens was too perfect. I decided to call those of my patients and 14% with the Rayner M-Flex IOL. Energy loss with the who received the Mplus to check their contrast sensitivity Mplus was only 7%; that is one-third the loss of energy that using a Topcon device to measure the contrast sensitivity. we are used to having with the Tecnis or other diffractive All patients demonstrated high levels of contrast sensitivi- lenses. I think this makes a huge difference with our patients. ty. Moreover, a frequent response was that they were able to read in bed using only a lamp on the bedside table— Breyer: One of my patients is a restaurant owner, and she and that would never happen with the ReStor, as all those is a type A personality. One of the issues she mentioned patients complained that they needed more light when during the preoperative examination was that she had trou- they had to read. ble reading in dim light. She wanted a multifocal IOL, but this was 2 years ago, and at that time I did not have a multi- Borasio: Optically, there is bound to be a reduction in focal lens that would work for her. But after I saw Gerd’s contrast sensitivity due to the multifocality and the coma images, which depict this gain of light, I implanted the that the lens induces. However, this is normally below the Mplus in her. Even being a very critical and difficult patient, patient’s subjective threshold, which is what is important for

8 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012 Advanced Multifocal IOL Technology

we are looking at HOAs, especially coma, to see how we can use the benefit of the coma to further improve the outcomes of these post-laser patients.

TALKING POINT NO. 5: COMA Mertens: Some of my colleagues have told me that there

Courtesy of Gerd U. Auffarth, MD is a lot of coma when you are implanting the Oculentis. But even though we can measure the coma, the patient does not experience any side effects from it.

Figure 7. Preliminary 12-month postoperative results:Visual per- Venter: Well we only measure the corneal coma, because formance with the LENTIS Mplus versus competitor products. that is all we really want to know. Any coma that is in the lens will be gone after the lens exchange. us. Alió recently compared multifocal IOLs with 3.00 D addition to monofocal lenses.2 He detected slightly higher con- Mertens: Is it important to measure the total coma after trast sensitivity with the monofocal for near BCVA, but this the Mplus is implanted in the eye? was below patients’ subjective threshold. He did find that the difference between the IOLs was not significant. Venter: We do not typically measure the total coma— only in patients who have had previous refractive surgery, Auffarth: I think that what we have to remember is that who have corneal pathology like forme fruste keratoconus, diffractive multifocal lenses have been available for 20 years, or in those patients who may have HOAs (especially coma) with a typical energy loss of approximately 20%. If we com- that can influence a better contrast sensitivity outcome. pare this to 7% (with the Mplus), the difference is not the 14% or 15% we showed in our study—the difference is a Breyer: I can add some value here. During a recent lecture 66% less loss of energy. I think if you look at it from this per- I gave in Bavaria, I emphasized that some patients reported spective, then you can understand the big difference seeing a half-moon shape underneath objects. Professor between this and other multifocal IOLs. Rentsch also spoke at this meeting and proved our reports using defocus pictures of the IOL’s point spread function. Venter: We found that contrast sensitivity with the However, as we both have experience with our patients, it Mplus was really similar to that of a monofocal lens. We usually disappears 1 or 2 weeks after implantation, and very actually now will use the Mplus on post-LASIK patients, few patients are affected by this phenomenon compared despite some people saying that it will increase the loss of with other multifocal IOLs. contrast sensitivity. Thus far, we have had excellent results in this population. We just use the coma and place the lens Aramberri: I would say that most patients do see that accordingly. shape after lens implantation. It is obvious for the first few weeks, and perhaps up to 3 months in some cases. Patients Breyer: Is this after hyperopic LASIK only or do you also have reported that it is most noticeable in spotlights at implant the Mplus after other laser treatments as well? night. If the lens is place in the normal way (up/down), all patients will initially notice this inferior comatic effect after Venter: We feel comfortable using this lens in patients implantation. But the eye will undergo a neural adaptation who have previously undergone either hyperopic or process, and after the first month or so the patient gets myopic LASIK. used to it and he or she is no longer bothered by it. Many surgeons worry about the presence of coma; OK, Breyer: With respect to the coma, correct? yes, it is there. But it is the same as if I asked you about the visual side effects of the concentric rings within other multi- Venter: Yes. focal IOLs. They are there, too, but we have gotten used to them through the years, and our patients overcome them Borasio: Have you seen good results in patients with high by neural adaptation. hypermetropia? But it is wise to do a customized treatment in the cornea with a reverse comatic pattern? The challenges with this are Venter: Our initial group of 50 patients all had a BCVA of (1) how do you calculate the comatic pattern and (2) how 6/6. We limited it to one laser procedure, and we only do you calculate the spherical equivalent of the total sys- implanted the Mplus in patients who had HOAs of 0.50 D tem? I think this is a very tricky and difficult solution. or less. So far, all of them have done well. We have not Another (safer) solution is secondary implantation of a exchanged one lens, so we think this strategy works. Now reverse optic add-on lens. As far as I know, this has never

JANUARY 2012 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I 9 LENTIS Mplus and LENTIS Mplus Toric

been tried before. But it could be useful when treating a Mertens: Do you use CTRs with this lens? patient who is still complaining 1 or 2 years after surgery. Aramberri: Not with the plate-haptic model. Pietrini: Is this common in patients with large pupils? Granberg: We have had significantly lower rates of PCO Mertens: No, it can happen in pupils as small as 5.5 after switching to the Mplus. We previously used a mix-and- mm. Patients were describing the problems they had with match strategy with other multifocal lenses, but 20% to 25% night vision, such as seeing double road markings and of eyes had PCO. Now we are at 5% with the Mplus. blurry headlights while driving a car at night. I now implant the lens upside down, and these visual distur- Mertens: Do you see it in the posterior capsule? Because bances have disappeared. Naturally, I have been wonder- sometimes when we see wrinkles or folds after implantation ing if putting the reading add nasally or temporally would of standard multifocal IOL, it has a large impact on the be better. Does anyone know? I only have experience with patient’s visual quality. Have you noticed the same thing up and down. with the Mplus?

Venter: I have put it temporally, and it worked well. Granberg: No, I have not noticed any wrinkles after implantation. I have seen some blur in the posterior capsule, Mertens: In both eyes? but because it does not bother the patient we do not perform Nd:YAG capsulotomy. Venter: Yes. But I have never implanted the reading add nasally, because I am afraid that it will cause dysphotopsias Mertens: With other multifocal lens designs, the Nd:YAG or comatic effects. capsulotomy is advantageous. Even when you think you have a clear capsule, you do the Nd:YAG capsulotomy and Mertens: What are the benefits of implanting the LENTIS the patient notices a big improvement in the visual quality. Mplus temporally? But with the LENTIS Mplus, a Nd:YAG is really only required if there is significant PCO. This is a great advantage, as I do Venter: These patients had astigmatism at 90º, so we not like to do a Nd:YAG capsulotomy within the first 6 ended up creating the incision and implanting the lens at months of surgery. 180º. In other patients, the lens was inside the eye with an incorrect astigmatic axis, so we had to rotate the axis to Granberg: We have a 3-month limit, and we do not use CTRs. 180º. These patients have done very well. Carbonara: I started implanting the Mplus in June 2010, Mertens: The Mplus Toric can be implanted upside and although I have no great numbers I have not needed to down and the axis remains perfectly aligned. It cannot be perform Nd:YAG capsulotomy yet. This is different than my implanted with the reading add nasally or temporally. experience with other multifocal IOLs, as I frequently used the Nd:YAG laser on these eyes. I recently switched from the TALKING POINT NO. 6: LENS MATERIAL C-loop model of the Mplus to the plate-haptic model after Mertens: Let’s discuss the lens material. What are your hearing others’ experiences. thoughts of the material design of the Mplus? Mertens: I implanted some Mplus lenses with the C-loop Aramberri: I have not worked with this type of lens design in the beginning, and noticed more stability than material in any other multifocal lens designs. Therefore, we with other C-loop designs because it is a thicker lens. But had to collect our own results to really judge what this with higher diopters, the lens will still tilt a few degrees. I material does and how it behaves over the long-term. In prefer the plate-haptic model, and actually the company terms of design, I started implanting the C-loop design in prefers the term four-point haptic. September 2009. The rate of Nd:YAG capsulotomy is low, which initially surprised me due to my experience with Borasio: I have been implanting the Mplus for approxi- other hydrophilic lenses. But 1.0 or 1.5 years after implanta- mately 6 months. It is too early to judge PCO rate, but so far tion, rates are still down, and we are doing less Nd:YAGs I have not had any that required Nd:YAG capsulotomy. than we did with other models. Breyer: I have also seen significantly less PCO since I start- Mertens: Do you still implant the C-loop? ed implanting the Mplus.

Aramberri: No, because I had a significant amount of Venter: We have done a significant amount of lenses— late-onset decentrations. I am now only using the 313. in excess of 10,000—and we have found that the PCO rate

10 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012 Advanced Multifocal IOL Technology is not as high as with other multifocal lenses. We never Granberg: We have implanted the Mplus in approxi- YAG until the patient’s dysphotopsias symptoms disap- mately 2,000 eyes. Before this, we were not in the practice pear, because if the symptoms persist we will exchange of using CTRs, and we have not even thought about it the lens to a 1.50 D add. This is how we treat all patients with the Mplus, because there have been no problems who present with ghosting, glare, and halos. In my experi- with centration. This is only with 6-month follow-up, ence, and I think this should be the case for any surgeon which is too early, but we have a big number of patients who is implanting many multifocal IOLs, you must be to draw from. prepared to exchange the lens if the patient’s symptoms persist. Breyer: I don’t think you have to implant a CTR, but in some cases it may be advantageous, not only for the stabili- Mertens: I am interested to hear that you exchange the ty of the IOL. Especially in younger clear lens extraction IOL for a lens with a low add, because I used the low add in patients, I look at it as a safety investment for the future. the beginning and I found that intermediate vision was worse than with the high add. Venter: In 2009, we started implanting the C-loop design. At the end of that year, the lens was either tilted or displaced Venter: True, but the glare is less. Of the 155 patients in 26 of 5,000 eyes. That is close to 0.5%. We managed all of who underwent lens exchange for the 1.50 D Mplus in the these patients by removing the C-loop and implanting the dominant eye and a 3.00 D in the nondominant, their four-point haptic lens. We were able to remove the C-loop reported incidence of glare at night was less than it was within 18 months without much of a problem. We have not with the 3.00 D in both eyes. The more satisfied the patient used any CTRs. One year ago we started using the 313, and was with reading, for which 63% of patients were, the less we have not seen any tilting of the lens. likely they were to complain. In the majority of patients, we only exchanged the dominant eye to a 1.50 D. That TALKING POINT NO. 8: OUTCOMES alleviated symptoms to such an extent that they were sat- Mertens: What are your patients’ visual results at dis- isfied with their vision. We have exchanged the 3.00 D tance, near, and intermediate? (See Refractive Lens Exchange Mplus for the 1.50 D Mplus in about 26 eyes, and in two With Customized Bifocal Toric IOL.) cases we did the exchange to 1.50 D add bilaterally. All of the others we only exchanged the 3.00 D for the 1.50 D in Aramberri: In general, for far and near vision, this lens is one eye. brilliant compared with other multifocal lenses. The point I stress to patients is the quantity of near vision. I tell my Mertens: Well 26 of 10,000 eyes is a small percentage. My patients that they can expect good newspaper-reading ability Nd:YAG capsulotomy rate is also very low. but they might need some other kind of correction for near for other small tasks. By using glasses, though, they will have Moore: I initially treated 50 patients with 1.50 D in the the perfect ability for small handwork. With this condition- dominant and 3.00 D in the nondominant eye. Overall, ing preoperatively, patients are extremely happy, and their these patients had earlier adaptation to the IOLs in relation expectations are met after surgery. to complaints of dysphotopsias; however, more patients complained of reduced reading ability compared to binocu- Granberg: I have had the same experience, Jaime. I believe lar 3.00 D treatments. My current practice is inferior near in the strategy of under-promise and over-deliver. I will tell adds with bilateral 3.00 D. my patients that 80% will be spectacle free for daytime work. In low-light conditions and at the computer, I tell Auffarth: I have had similar results. Even in our initial them that they will need spectacles. study, only occasionally did a patient require Nd:YAG laser. So the PCO rate seems to be very good with the Mplus. Carbonara: I remind patients that there is a good chance for spectacle independence, because I am sure the postop- TALKING POINT NO. 7: CTRS erative results will be superb. Up to now, I have not had any Mertens: Are any of you afraid that, if you do not use a refractive surprises. CTR, that the lens will eventually rotate? Borasio: I analyzed my outcomes just before coming Aramberri: I have stopped implanting a CTR now that I here, and this is for 20 eyes. There is total spectacle inde- have transitioned to the 313 platform, and I have had no pendence in 28% of my patients; 22% need a near addition problems with centration at 1 year. of 1.00 D, 17% need about 1.25 D, and 17% need a 2.00 D near add. In terms of distance UCVA, 56% of eyes achieved Moore: Other than for pseudoexfoliation, I do not use 6/6 or better and 89% achieved 6/9 or better. Plotting the CTRs with the new 313 platform. astigmatism before and after the operation on double-

JANUARY 2012 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I 11 LENTIS Mplus and LENTIS Mplus Toric Courtesy of Edmondo Borasio, MedCBQ Ophth, FEBO angle polar plots has shown excellent reduction of the A B astigmatism both after Mplus and Mplus toric IOL implantation (Figure 8).

Mertens: Did you specifically ask for what kind of near- vision tasks patients needed their reading glasses?

Borasio: Yes. In total, 94% of patients achieved N4, which is smaller than newspaper print.

Mertens: So you still have a relatively high percentage of patients using reading glasses. Figure 8. (A) Pre and (B) postopereative astigmatism distribution after Mplus and Mplus Toric IOLs; calculated with the Eye Pro Borasio: Only for certain tasks. They are happy 90% of 2011.Arithmetic and summated vector means are also reported. the time during the day without additional correction. Then they may need a small addition for certain tasks, such as Mertens: I have had a similar experience. The most difficult reading a book for a long time or reading in dim light condi- patients to satisfy are those with -1.25 to -1.50 D of myopia, tions. What makes patients happy with the Mplus is the because they are used to reading small print without glasses intermediate vision. Our lives are mainly at the intermediate or contact lenses. We must be especially careful when coun- distance, so this is extremely important to patients. seling these patients before surgery. I tell them that they will be spectacle free for 80% of their daily activities; this is on the Venter: We have data for a fairly large number of patients. safe side. Indeed some of them will need to use 1.00 D add for We promise patients that they will have good newspaper some tasks, but some won’t need any add. vision. When we look at our patients’ reading ability, 95% achieve N8 or better. In terms of distance UCVA, 83% are Auffarth: I tell patients that there is a difference between 20/20 or better. Intermediate vision is good with the lens as spectacle independence and spectacle freedom. Spectacle well, so we only have a small number of patients who might independence means that they will always achieve some need a 1.00 or 1.50 D add. We obtained a questionnaire on type of independence from spectacles, whereas spectacle quality of vision (FDA format) from 1,000 patients at 1 year freedom means that they will never need spectacles. I tell with the 3.00 D add Mplus, and 94% of patients stated that patients that they may achieve 100% of the visual acuity they never wear any glasses. that they like but only 90% of the day will they be independent from spectacles. But there are some infamous Moore: In my initial experience using 1.50 and 3.00 D patients, like engineers for example, who expect spectacle Mplus IOLs, the mean (± SD) logMAR UCVA was 0.04 freedom. In general, these patients won’t do well with multi- (± 0.25), contrast sensitivity was 1.57 (± 0.13), near vision focal lenses. If they understand the difference between spec- was M0.75 (± 0.33) at 32 cm and M0.90 (± 0.27) at 66 cm, tacle independence and spectacle freedom, then I think and reading speed was 161.74 words/min (0.4 logRAD at they are on the right track. 32 cm). Patients were still complaining slightly, similar to what Dr. Borasio mentioned, that some of their reading Breyer: The wording that we use with our patients is vital. was not as good. I started implanting the 3.00 D in both I would like to go back to those patients we were referring eyes and where necessary aimed for -0.40 D in the non- to earlier who have double vision after multifocal lens dominant eye, based upon early visual results in the first implantation. If a patient comes back several months after eye treated (dominant eye). I have found that I have been surgery complaining of double vision, I will use the following able to improve subjective near vision results with this explanation: “It is good you are having this double vision; technique. otherwise, the IOL wouldn’t be working properly.” It is amaz- ing what this one sentence does to change the patient’s per- Pietrini: One of the strengths of this lens is certainly the spective. They come back 2 or 3 months later and they are level of intermediate vision it provides. Even though near content with their vision (Figure 9). vision is sometimes insufficient, patients (especially those with high myopia) should only need a small add for special Auffarth: You can also tell the patient that it is just a mat- tasks. In some cases, the only reason a near add is needed is ter of neural adaptation and after 3 to 6 months these dou- because the patient is demanding. Concerning far visual ble images will resolve themselves. acuity, I think that depending on the patients’ needs, we can fine-tune things to favor distance vision. But if we want to Mertens: I tell my patients the same thing, Gerd. I tell have good vision, we should target smaller myopic ranges. them that there are two images in the eye, one for far and

12 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012 Advanced Multifocal IOL Technology

REFRACTIVE LENS EXCHANGE WITH CUSTOMIZED BIFOCAL TORIC IOL By Erik L. Mertens, MD, FEBOphth ity, 100% of patients were J1 or better at 1 month. For cumulative distance-corrected near visual acuity, 100% of patients In my experience, not only does the LENTIS Mplus IOL were J4 or better at 1 month, 86% were J2 or better, and 33% (Oculentis GmbH) score very high on the patient satisfaction were J1 or better. scale, but it also has a much lower incidence of glare and halos I also have results for 24 eyes at 12 months. In this group, compared with other multifocal IOLs. Additionally, stability in visual acuity remained unchanged in 58% of patients, while the capsular bag is excellent, making this lens a top choice in 29% gained 1 line and 4% gained 2 lines. All patients remained my clinic. at J1 for distance-corrected intermediate visual acuity, and My most recent results include data for 50 eyes implanted 100% remained J4 or better for distance-corrected cumulative with the Mplus. Preoperatively, patients’ mean spherical equiv- near visual acuity. There was a slight improvement in the num- alent was -0.34 ±4.17 D (range, -13.75 to 6.75 D), with a mean ber of patients who were J2 or better (88% vs 86%) and a sig- sphere and cylinder of 0.58 ±4.01 D (range, -11.75 to 7.00 D) nificant increase in the number of patients who were J1 or bet- and -1.84 ±1.15 D (range, -5.50 to -1.00 D), respectively. ter (54% vs 33%). Patients ranged in age from 47 to 75 years, and the follow- There was a slight decrease in near vision compared with up rate was 100%. The mean improvements in spherical equiv- other multifocal lens designs, and 14% of patients reported a alent, sphere, and cylinder at 1 month were 0.07 ±2.27 D shadow when reading. I believe that tilt can cause this side (range, -0.38 to 1.00 D), 0.13 ±0.32 D (range, 0.00 to 1.00 D), effect; however, rotational stability is excellent at 1 month as and -0.12 ±0.36 D (range, -1.25 to 0.00 D), respectively. well as at 12 months. Additionally, 22% of eyes gained 1 line of visual acuity, 10% In conclusion, in my cohort of 50 eyes implanted with the gained 2 lines, and 4% gained more than 2 lines at 1 month. Mplus, patients had good distance, intermediate, and near The visual acuity remained unchanged in 47% of eyes at 1 vision. The rate of glare and halos is infrequent, and overall my month. In terms of distance-corrected intermediate visual acu- patients have been happy with this lens.

one for near. When looking at an object at a distance, near because we can correct two big problems for them, aberra- focus is blurry, and the brain has to learn to get rid of the tions and astigmatism. If I had to list two of the most posi- near focus. It is the other way around when reading. It is tive aspects of the Mplus Toric, I would say that the first is important that patients understand this concept, and after that this lens provides a customized cylinder. I really like to a couple months most of my patients do not mention these know that all of the cylinder in the cornea will be compen- double vision symptoms anymore. Like Gerd said, the brain sated for. I no longer need to round calculations, and there- is a powerful thing. fore the correction is more precise. Additionally, the postoperative calculations really work well. The lens is correctly TALKING POINT NO. 9: manufactured, and it provides exactly what it promises. I STRENGTHS AND WEAKNESSES think that is great. This is the first point. Mertens: Moving on, let’s discuss the strengths and weak- The second point is that centration is excellent. When nesses of the Mplus Toric technology. Are there areas that there are only two marks in the optic for alignment, as need improvement? many other lenses have, centration can be really tricky, as it is hard to know if you are on axis in the operating room and Aramberri: I have found that most of the lens’ features under the microscope. But with more reference marks it is are strengths. The Mplus Toric has seduced me as a multifo- easier to centrate the lens. With the Mplus, there are two cal toric because of its total correction zones and the excel- horizontal lines, one asymmetric line, and the optic marks. I lent postoperative results. I think we all share this percep- also make a point to mark the vertical lines in these eyes tion, and in fact I have found that the higher the cylinder, preoperatively. Therefore, I have four reference points, and I the happier the patient is after surgery. This is logical, also put them on the toric lens at the slit lamp. Once I have Courtesy of Detlev Breyer, MD Courtesy of Detlev Breyer,

A B

Figure 9. (A) Patient questionnaire at 1 month postoperative. (B) Patient questionnaire at 3 months postoperative.

JANUARY 2012 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I 13 LENTIS Mplus and LENTIS Mplus Toric Courtesy of Dominique Pietrini, MD Courtesy of Dominique Pietrini, MD

Figure 11.The IOL was implanted in the eye at 13º to Figure 10. One month and 1 year measurements of the internal compensate for -3.75 D of corneal astigmatism. Here, pre- wavefront show that the IOL is perfectly stable. and postoperative corneal astigmatism are shown. Courtesy of Dominique Pietrini, MD Courtesy of Dominique Pietrini, MD

Figure 12. The cylinder of the IOL was positioned in the eye Figure 13. After implantation of the Mplus in this eye, the at 121º to compensate for -3.74 D of preoperative astigma- residual astigmatism was only 0.09 D. tism. Here, pre- and postoperative corneal astigmatism are shown. be implanted. After that, the software does the calculation for the toric correction. With other IOL models, I had to the patient in position, I implant the lens and rotate it into send all the collected data to the company, and they did the position. I have so many references that I feel that centration calculation directly. I never knew how they did it, nor which is always perfect. formula they used and, in the end, I could have been responsible for their mistakes. This is another reason that I Granberg: The toric lens is just as easy to implant as the like the Mplus Toric. I like the fact that, with Oculentis, I can standard Mplus. I make one marking at the 6-o’clock posi- calculate the power of the IOL and they do the calculation tion, and I feel that is safe enough to achieve perfect centra- only for the toric power of the IOL. tion. Additionally, the option for customized cylinder is nice to have. The only thing that is a drawback is that you have Borasio: I like the four-point haptic design, as it is easy to to wait 2 or 3 weeks to get it. If you are implanting a lens implant. In one case, the distal haptic of the C-loop design with customized cylinder in a good number of your got stuck between the plunger and the cartridge, probably patients, that is a lot of logistics. because I hadn’t assembled it correctly. Looking at its position inside the cartridge, I do not think I advanced it Carbonara: Another thing that my patients appreciate is enough, and it became stuck. To achieve good alignment, I that there is no jump between the near and far vision with always mark the horizontal meridian at the slit lamp before the Mplus as well as the Mplus Toric. taking the patient to the operating theater. But what I would like to talk about is biometry. In contrast to my experience with some competitor lenses, Venter: The lens with the four-point haptic is easy to Oculentis lets me calculate the power of the Mplus lens to implant. Additionally, because the astigmatism is prealigned,

14 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I JANUARY 2012 Advanced Multifocal IOL Technology Courtesy of Dominique Pietrini, MD Courtesy of Dominique Pietrini, MD

Figure 14. With a 10º misalignment of the IOL, the patient Figure 15. Even though this IOL was misaligned, there is still had -1.86 D of residual astigmatism. no presence of coma postoperatively.

you can leave the lens at 90º, eliminating the need to move these visuals were made with the KR-1W analyzer. It is really the lens anywhere inside the capsular bag. Another great interesting in the case of toric lens implantation, because thing is the stability of the Mplus. We have looked at the 6- you have the topographic map and the topographic axis, month results in 350 eyes, and all of them were within 10º but you also have the wavefront, which can be composed in of the target. the cornea or in the IOL itself. So if we look at Figure 11, we can see that the patient has -3.75 D of corneal astigmatism Breyer: Another advantage of the Mplus is the fact that preoperatively at 18º. After surgery, the patient has -0.60 D it can be implanted through an absolutely astigmatism of residual astigmatism at 60º, which is then corrected with neutral incision of 1.5 mm. You do not have to discuss refraction. The IOL itself is -3.72 D at 103º. The axis of surgically induced astigmatism with the patient. Surgery implantation was 13º instead of 18º. becomes more precise and easier to plan, which is espe- In Figure 12, the patient had -3.74 D of corneal astigma- cially important for toric multifocal IOL. That is when art tism at 27º, and we positioned the Mplus IOL in the eye at becomes science. 121º. The patient had -0.50 D of residual astigmatism after surgery. The difference of axis is only 4º in this case, and TALKING POINT NO. 10: STABILITY there was a small amount of residual astigmatism. Mertens: How do you measure stability? These results are extremely interesting, because you can analyze the lens itself and you can ensure that, if you place Venter: We measured refraction, and we dilated the pupil the lens in the right axis, you will have good results. and checked the axis of astigmatism. Then, at 6 months, we checked the refraction, which we have from 1 week, 1 Mertens: For every degree of misalignment, you lose 3%. month, 3 months, and 6 months postoperatively. These were all within our intended refraction. Stability is a real Pietrini: When you implant the lens exactly on the axis, important aspect for this toric lens and one of the reasons it there should be no residual astigmatism. In one case (Figure works so well in the eye. 13), the difference was 0º, and there was only 0.09 D of residual astigmatism. In this last case I would like to share, Breyer: One great tool is the KR-1W aberrometer, as it the patient had high astigmatism preoperatively, and the simultaneously measures to total, corneal, and internal astig- residual astigmatism after IOL implantation was -1.86 D matism and aberrations. because of a 10º misalignment (Figure 14). When we analyzed the result, we were careful not to incriminate the sur- Mertens: Dominique, I understand that you have some gery or the patient. We tried to evaluate the coma, but marvelous pictures depicting the stability of this lens. even in cases of misalignment, there is almost no coma Would you like to share those with us? (Figure 15).

Pietrini: Figure 10 does indeed showcase the stability of Mertens: Thank you for sharing these case studies with the Mplus. In most cases where stability is an issue, the us, Dominique. We are able to learn a lot from them, just as problem stems from the patient or the surgeon, not the we were able to learn a lot by sharing our thoughts and our lens. Complications can occur when we do not perform experience with the LENTIS Mplus. I think this was a great perfect surgery. discussion, and I thank you all for attending. ■ We also wanted to determine the IOL’s stability and the 1. www.oculentis.com/profLentisMplus.html#. Accessed January 3, 2012. right positioning, so we looked at the K1 values with topog- 2. Alió JL, Pinero DP, Plaza-Puche AB, Chan MJ. Visual outcomes and optical performance of a raphy and simultaneously with the wavefront analyzer. All monofocal intraocular lens. J Cataract Refract Surg. 2011;37(2):241-250.

JANUARY 2012 I SUPPLEMENT TO CATARACT & REFRACTIVE SURGERY TODAY EUROPE I 15 Oculentis GmbH Competency in Intraocular Surgery Am Borsigturm 58 13507 Berlin, Germany Tel: +49 30 43 09 55-0 Fax: +49 30 43 09 55-11 E-mail: [email protected] Web: www.oculentis.com